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Findings

A written finding is a formal document handed down by a coroner following an investigation into a death or fire and is generally the final step in the coronial investigation process. A written finding is made regardless of whether an inquest is held or not.

A written finding following an investigation into a death will usually, if possible, include:

  • the identity of the person who died
  • the time, date, and location where the death occurred
  • a summary of the evidence relating to the circumstances of the death, in some cases
  • comments or recommendations made by the coroner aimed at preventing similar deaths, in some cases.

Findings are published when:

  • an inquest was held
  • recommendations have been made
  • a coroner otherwise orders they be published.

Findings handed down and published are available below.

Search older findings on the Australasian Legal Information Institute database (AustLII).

Please consider that it may be upsetting to read details about a death or fire in an inquest finding. Some information may be graphic or distressing.

Use the search field above to locate a finding. You can search for a name, a case number, type of death or location of death.

Any person may apply for some or all of a finding to be reviewed and/or appealed.

    Recommendations

    The Coroners Act 2008 allows a coroner to make recommendations as part of their finding following an investigation into a death or fire.

    Recommendations can be made to any Minister, public statutory authority or entity that may help prevent similar deaths. Anyone who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken.

    The Court will publish inquest findings with recommendations and the subsequent responses below.

    Findings list

    Name Case ID Case type Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Dean Scott Westbrook COR 2005 4176 Finding into death with inquest 25/02/2010 State Coroner Judge Jennifer Coate
    JM COR 2009 4213 Finding into death with inquest 09/12/2013 Coroner Kim M. W. Parkinson
    Russell John Robert McLarty COR 2006 4248 Finding into death with inquest 26/06/2013 Coroner Dr Jane Hendtlass
    James Daniel Simpson COR 2014 4276 Finding into death with inquest 05/11/2015 Coroner Peter White
    Moufid Sawan COR 2011 4320 Finding into death with inquest 28/08/2015 Coroner Audrey Jamieson
    Noella Rae Clohesy COR 2006 4376 Finding into death with inquest 29/08/2014 State Coroner Judge Ian L Gray
    Derek Hamilton COR 2014 4627 Finding into death with inquest 18/05/2017 Coroner Audrey Jamieson
    Grant Phillip Scheibner COR 2014 4805 Finding into death with inquest 23/04/2015 Deputy State Coroner Iain West
    Tzu Lin Yang COR 2010 4903 Finding into death with inquest 06/07/2011 Deputy State Coroner Iain West
    Elijah Michael Shelley COR 2008 4973 Finding into death with inquest 01/09/2011 Coroner John Olle